[PROVISIONAL TRANSLATION FROM Persian]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

Islamic Republic of Iran

Ministry of the Interior

Personal Status Registration Office

Excerpt from Death Certificate

[Illegible] 206227 Series 1-2

 

[Illegible] Year: 1370 [1991] House number-----, Alley-----, City of Tehran, [illegible], Village-----, Town-----, Mr. Bahman, Surname Samandari, Son of Azizollah and Bahiyyeh, Born 1318 [1939], Identification number [redacted], issued in the City of Tehran; part of Area 3 of the Personal Status Registration Office of ----- has died of illness/accident and his death has been registered in the deceased book [for] year 1371 [1992] of The Personal Status Registration Office of ----- at number 14042.

This intact and unmarred copy of the death excerpt was delivered to Mr./Mrs -----, Son/Daughter ----- in response to his/her written request.

[Illegible] signature of the representative and stamp, [illegible] Tehran area, Personal Status Registry

[Signature over official stamp]

 

[Handwritten note, number and date at the bottom of the page]

Date of death 27 Esfand 1370 [17 March 1992]

[Official stamp]

[Signature]